Priv/F2 IR 816 October 2010 Criminal record check For Ministry of Justice Office Use ONLY MoJ Request Number Request by third party under the official information act 1982 for a copy of an individual s criminal convictions held on the Ministry of Justice s computer systems IN CONFIDENCE WHEN COMPLETED SECTION 1: SUBJECT S AUTHORITY TO RELEASE INFORMATION TO A THIRD PARTY I hereby authorise the Privacy Unit, Ministry of Justice, to release a copy of my personal information, to the undersigned Third Party, for the purpose of: Tick the report required: Pre-employment vetting All convictions report Traffic convictions report Insurance claims vetting Other (specify) Signature of subject Date I wish to receive a copy of the information provided to the Third party. Yes No SECTION 2: THIRD PARTY DETAILS Third Party Name Details Full Name of Third Party Inland Revenue Full name and address of the person or agency the third party is acting for (if applicable), if not Inland Revenue Third Party Reference Number (if applicable) Third Party Address Details PO Box or Street address Postcode Signature of Third Party (Hiring Manager) PO Box 12 451 Thorndon Wellington 6144 New Zealand Hiring Manager s Name Hiring Manager s Office The term subject refers to the person whose criminal convictions are being requested. The term third party refers to the requestor or ultimate intended recipient, such as an employer, insurance company, credit agency, et cetera. The Ministry of Justice will process this request as soon as is reasonably practicable, and in any case no later than 20 working days from receipt of this application. This application, associated letters and reports will be disposed of three months after processing the response. Form continues overleaf
SECTION 3: SUBJECT S DETAILS (Please print in pen) Personal Details Date of Birth Place of Birth Gender (Male/Female/Indeterminate) Day Month Year Previous Names Maiden Name, Aliases Postal Address Current Residential Address P.O Box or Daytime Phone Number Home Phone Number Fax Number Previous Two Residential Addresses Form continues overleaf IR 816
SECTION 3: SUBJECT S DETAILS (continued) Subject s Identification Please attach a photocopy of the subject s identification. The identification may be a Driver Licence OR if subject does not hold a driver licence, a Passport. If subject has neither, the subject will need to complete Section 4. Driver Licence Passport SECTION 4: PROOF OF IDENTITY ONLY TO BE COMPLETED IF SUBJECT DOES NOT HAVE A DRIVER LICENCE OR PASSPORT Subject to ask someone who can confirm their identity to fill in this section The person who identifies subject must: have known subject for more than 12 months be aged 18 years or over have a day time phone number not be a relative not live at the same address be contactable during normal business hours Daytime Phone Number Home Phone Number Fax Number I declare that I have personally known: For years and vouch for his/her identity Signature of identifier If subject is unable to get someone to complete Section 4, they must complete a statutory declaration. The relevant form can be obtained from the local District Court or by contacting the Privacy Unit on 04 918 8800. Security Unit, PO Box 12 451, Thorndon, Wellington Phone (04) 890 1934 or (04) 890 1500 IR 816
INFORMATION ABOUT OFFENCES OFFENCE GENERALLY ACCEPTABLE GENERALLY NOT ACCEPTABLE 1. Offences against the Crimes Act 1961 (reprinted 1979) and amendments 2. Offences against the Accident Insurance Act 1998 (and amendments) relating to fraud 3. Offences against the Social Security Act 1964 (reprinted 1994) and its amendments, relating to benefit fraud A person sentenced by a civil or military court for an offence in relation to the Crimes Act 1961, the Accident Insurance Act 1998 and the Social Security Act 1964 to: (a) a fine (b) a period of periodic detention (c) a care of supervision order (d) a period of community service (e) a suspended sentence relating to a non-custodial sentence. Providing no re-offence has occurred, and there is a period of 10 years from the date of the last conviction when only fined, otherwise on expiry of the court order, whichever is the longer. A person sentenced by a civil or military court for an offence in relation to the Crimes Act 1961, the Accident Insurance Act 1998 and the Social Security Act 1964 to: (a) (1) a term of imprisonment (2) a period of corrective training (3) a suspended sentence relating to a custodial sentence, and/or (b) one or more convictions under any of the following Acts: (1) Crimes Act 1961 (2) Misuse of Drugs Act 1976 (3) Social Security Act 1964 (Section 127) (4) Accident Rehabilitation and Compensation Insurance Act 1992 (Section 166) (5) Income tax and GST legislation (occurring within the time period as detailed within these pages) 4. Offences against the Misuse of Drugs Act 1975 (reprinted 1990) and amendments Convictions for the possession and use of controlled drugs. A person sentenced by a civil or military court for an offence in relation to the Misuse of Drugs Act 1975 to: (a) a fine (b) a period of periodic detention (c) a care of supervision order (d) a period of community service (e) a suspended sentence relating to a non-custodial sentence. Providing no re-offence has occurred, and there is a period of 3 years from the date of the last conviction when only fined, otherwise on expiry of the court order, whichever is the longer. (a) Where a person has been convicted of dealing in controlled drugs. (b) More than one conviction for the possession and use of controlled drugs. (c) A person sentenced by a civil or military court for an offence under this Act to: (1) a term of imprisonment (2) a period of corrective training (3) a suspended sentence relating to a custodial sentence. 5. Taxation offences A person convicted by a court of any offence related to taxation, or charged penal tax where default was involved and provided that the occurrence was prior to applying for the position. Providing no re-offence has occurred and there is a period of 5 years from the date of conviction where only fined, or on the expiry of any court order, whichever is the longer and all tax outstanding and penalties have been paid. A person convicted by a court of any offence related to taxation, or charged penal tax where fraud was involved. 6. Minor offences A person convicted: (a) by a District Court for a summary offence for which the defendant is not liable on conviction to a sentence of imprisionment or to a fine exceeding $500, or (b) by an overseas court for any minor offence within the meaning of the paragraph (a) above. N/A 7. Convictions under the Transport Act 1962 and amendments, and the Transport Act 1986 and amendments A person convicted: (a) of any offence against any of the provisions of Parts II to V of the Transport Act 1962 or against any regulation or bylaw made under any other enactment and relating to the use of vehicles or parking places or transport stations, that is punishable on summary conviction by a fine of an amount not exceeding $500 and that is not punishable by imprisonment. The offences include careless, reckless or dangerous driving, driving while disqualified, driving without a licence, driving while under the influence of alcohol or drugs, or other offences dealt with by a fine or other court order: (b) by an overseas court for any minor offence within the meaning of paragraph (a) above. Providing no re-offence has occurred, and there is a period of 1 year from the date of the last conviction when only fined, otherwise on expiry of the court order, whichever is the longer. Generally acceptable where driving IRD vehicles is not part of the person s employment with IRD. A person convicted under the Transport Act 1962 or the Transport (Vehicle and Drivers Registration and Licencing) Act 1986 which involved careless, reckless or dangerous driving, driving while disqualified, driving without a licence, driving while under the influence of alcohol or drugs, or other offences dealt with by fine or other court order, where: (a) a second conviction or repeated convictions have occurred, and (b) the person will be required to drive an IRD vehicle as part of the person s employment with IRD.
Criminal Record Check IR 816 (October 2010) Request for Personal Information Held by Ministry of Justice Instructions for Completion This form, IR 816 (October 2010), replaces immediately all previous Request for a Copy of Personal Information forms relating to checks for criminal records. It is for use when you employ: New permanent staff part or full time Temporary (fixed term and casual) staff Contractors and consultants Staff provided by employment agencies Named individuals from companies providing ongoing services to the Department, e.g. cleaners Note 1: This form is actually a Ministry of Justice form which Inland Revenue has received permission to personalise. Hence the Ministry of Justice logo and reference number field. You will note that they refer to requestor being the Applicant as the Subject. Note 2: The form must be completed in pen and all entries must be legible. Section 1 Have subject (applicant) sign, date and indicate whether they wish to receive a copy of the information. If no indication is made, it will be interpreted as NO. Section 2 Hiring Manager to sign as Third Party representative. Hiring Manager s name and site to be entered legibly. Section 3 Have subject (applicant) complete all required fields. Have subject (applicant) supply the original of their drivers licence or passport as identification. Note, the signature must be present. No other form of identification is acceptable. See section 4 if identification cannot be supplied. After verifying to the best of your knowledge that the identification is genuine, take a photocopy of the identification and return the original identification document to the subject (applicant). You do not need to have the copy certified to be true and correct. Section 4 (This section only needs to be completed If subject (applicant) is unable to supply the required identification under section 3.) Review with the subject (applicant) the criteria necessary for someone to serve as an Identifying Person. Tell subject (applicant) to get an Identifying Person to fill out this Section Proof of Identity and have the Identifying Person sign. If subject (applicant) is unable to get someone to complete section 4, then they must complete a statutory declaration. The relevant form can be obtained from the local District Court, Privacy Unit of the Ministry of Justice by phoning 04 918 8800 or the Security Unit. Continued overleaf
Processing of Completed Form Send the completed form and photocopy of ID or Statutory Declaration to the Security Unit at P O Box 12 451, Thorndon, Wellington. Security Unit will quality check form, log the document and forward it to the Ministry of Justice to conduct the check. Ministry of Justice will process the form as soon as is reasonably practical and in any case no later than 20 working days from receipt of the application. Upon receipt at the Security Unit of the findings by the Ministry of Justice, the Security Unit will compare the findings against the criteria and listed in Section 2 of the Security Manual and attached to the IR 816, make a recommendation regarding the subjects (applicant s) suitability and inform the Panel Chairperson of that recommendation. Criminal Convictions History Criminal records concealed under the Criminal Records (Clean Slate) Act 2004 are not part of Inland Revenue s check. In respect of any previous criminal convictions it is not intended that all people with a criminal record be barred from being appointed to vacancies in the Department. There are convictions that will have no bearing on a person s general acceptability for employment. These may include convictions for minor offences only or for offences over 10 years old, where no repeat offence has occurred. No record of any conviction is held on personal files or is used for any other purpose. Information on Generally Acceptable and Generally Not Acceptable offences is attached to this form and the Application for Vacancy IR 811.